1184692444 NPI number — DR. SHARON SUE KELLY DO

Table of content: (NPI 1811183510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184692444 NPI number — DR. SHARON SUE KELLY DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
SHARON
Provider Middle Name:
SUE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184692444
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30309
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29417-0309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-284-3400
Provider Business Mailing Address Fax Number:
843-566-8780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6116 E WARREN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80222-5752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-512-0888
Provider Business Practice Location Address Fax Number:
303-512-2288
Provider Enumeration Date:
03/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207ZB0001X , with the licence number:  31623 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X , with the licence number: 31623 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01316231 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 36586269 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 843385 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: Z6603 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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